Seizure in children

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Seizures (Paroxysmal Disorders):

Seizures ( Paroxysmal Disorders) Seizures in Childhood G.R. Jeloudar MD


seizure Transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain Focal (partial ) seizures: limited to part of one cerebral hemisphere Generalized seizures: involvement of all of both hemispheres Febrile seizures Acute symptomatic seizures: secondary to an acute problem ( electrolyte imbalance or meningitis)

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sudden reversible changes in mental status or somatosensory stereotyped and repetitive seconds to minutes (rarely hours) Aura postictal state

Febrile Seizures:

Febrile Seizures Age :6 - 60 mo Temperature of 38°C or higher that are not the result of central nervous system infection or any metabolic imbalance Absence of a history of prior afebrile seizures Simple febrile seizure : generalized tonic- clonic , Fever Maximum of 15 min not recurrent within a 24-hour period do not have an increased risk of mortality

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Complex febrile seizure : prolonged (>15 min ) focal recurs within 24 hr have an approximately 2-fold long-term increase in mortality Febrile status epilepticus is a febrile seizure lasting > 30min Febrile seizures recur in approximately 30% of those experiencing a first episode, in 50% after 2 or more episodes, and in 50 % of infants <l yr old at febrile seizure onset Recurrent simple febrile seizures : do not damage the brain , incidence of abnormalities of behavior, scholastic performance , neurocognitive function, or attention.

WORK-UP Febrile seizures often occur in the context of otitis media, roseola and human herpesvirus 6 (HHV6) infection, shigella :

WORK-UP Febrile seizures often occur in the context of otitis media, roseola and human herpesvirus 6 (HHV6) infection, shigella

Lumbar Puncture :

Lumbar Puncture Lumbar puncture is recommended in children <12 mo of age after their first febrile seizure to rule out meningitis. It is especially important to consider if the child has received prior antibiotics that would mask the clinical symptoms of the meningitis The presence of an identified source of fever, such as otitis media, does not eliminate the possibility of meningitis Seizures are the major sign of meningitis in 13-15 % 12 and 18 mo of age should also be considered for LP


Electroencephalogram EEGs performed within 2 wk of a febrile seizure often have nonspecific EEG should restricted to special cases in which epilepsy is highly suspected If the patient does not recover immediately from a seizure, then EEG can help distinguish between ongoing seizure activity and a prolonged postictal period

Blood Studies:

Blood Studies Not routinely recommended in the work-up of a child with a first simple febrile seizure Blood glucose should be determined only in children with prolonged postictal obtundation or those with poor oral intake If clinically indicated (e.g., in a history or physical examination suggesting dehydration ) these tests are indicated (serum electrolytes, calcium, phosphorus, magnesium, and (CBC)


Neuroimaging CT or MRI is not recommended in evaluating the child after a first simple febrile seizure The work-up of children with complex febrile seizures needs to be individualized EEG and neuroimagmg , particularly if the child is neurologically abnormal


TREATMENT antiepileptic therapy , continuous or intermittent, is not recommended for children with one or more simple febrile seizures If the seizure lasts for >5 min, then acute treatment with diazepam, lorazepam , or midazolam is needed Alternatively, buccal or intranasal midazolam Febrile status epilepticus IV benzodiazepines, phenobarbital , phenytoin , or valproate During febrile illnesses (0.33 mg/kg every 8 hr during fever) reduce the risk of seizures in children known to have had febrile seizures with previous illnesses.


Epilepsy ≥2 unprovoked seizures occur in a time frame of >24 hr Epileptic syndromes: represent clinical entities where in age , pattern of clinical event, EEG abnormality, natural history , and prognosis are distinctive

Classification of Seizures and Epileptic Syndromes:

Classification of Seizures and Epileptic Syndromes PARTIAL SEIZURES: Simple partial (consciousness not impaired) Motor signs Special sensory (visual, auditory, olfactory, gustatory, vertiginous , or somatosensory) Autonomic Complex partial (consciousness impaired) Psychic (déjà vu, fear, and others) Impaired consciousness at onset Development of impaired consciousness Secondarily generalized seizures Jacksonian seizures


GENERALIZED SEIZURES: Absence Typical Atypical Tonic Clonic Tonic- clonic Minor motor Atonic Myoclonic


EPILEPTIC SYNDROMES: Benign focal epilepsy (benign rolandic epilepsy, benign centrotemporal epilepsy) Juvenile myoclonic epilepsy Infantile spasms (West syndrome) Lennox- Gastaut syndrome Acquired epileptic aphasia (Landau- Kleffner syndrome) Benign neonatal convulsions

Partial Seizures:

Partial Seizures SIMPLE PARTIAL SEIZURES (SPS) consciousness is not impaired sensory (auras) or brief motor : Brief motor seizures are the most common and include ,focal tonic, clonic or atonic seizures COMPLEX PARTIAL SEIZURES (CPS) consciousness is impaired usually last 1-2 min and are often preceded by an aura Automatisms (chewing, manipulating the sheets , walking ) Often there is salivation,dilation of the pupils, and flushing or color change.

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jacksonian seizures : partial seizures spread to involve the whole brain and produce a generalized tonic- clonic seizure Uncinate seizures: arising from the medial temporal lobe manifest with an olfactory hallucination Gelastic seizures: originating from hypothalamic tumors are spells of uncontrolled laughter

Generalized Seizures Generalized Tonic, Clonic, and Tonic-Clonic Seizures (Generalized Major Motor Seizures) :

Generalized Seizures Generalized Tonic, Clonic , and Tonic- Clonic Seizures (Generalized Major Motor Seizures) Consciousness and control of posture are lost Tonic stiffening and upward deviation of the eyes Pooling of secretions , pupillary dilation , diaphoresis , hypertension , and piloerection are common Clonic jerks follow the tonic phase Tonic again Flaccid and urinary incontinence may occur Irritability and headache Status epilepticus : Generalized tonic- clonic activity lasting longer than 20 minutes , or repeated seizures without restoration of consciousness for more than 30 minutes and may lead to irreversible brain injury


ABSENCE SEIZURES Hallmark : brief loss of environmental awarenes accompanied by eye fluttering or simple automatisms , such as head bobbing and lip smacking Begin between 4 and 6 years of age Neurologic examination and brain imaging are normal EEG : 3-Hz spike-and-wave activity Provoked by hyperventilation or strobe light stimulation and usually last a few seconds

Differentiating absence epilepsy from partial complex seizures :

Differentiating absence epilepsy from partial complex seizures Both seizure types are characterized by cessation of activity , staring , and alteration of consciousness and may include automatisms Partial complex seizures : The automatisms are usually more complicated Often followed by postictal confusion Occur spontaneously and usually last several minutes Rarely have more than one or two seizures in a day


GENERALIZED MOTOR SEIZURE Generalized tonic- clonic seizures Loss of consciousness Sudden cry Upward rolling of the eyes Generalized tonic contraction with falling, apnea, cyanosis Incontinence and a postictal period often follow( 30 min to several hours)


EPILEPTIC SYNDROMES Benign focal epilepsy ( rolandic epilepsy ) Begins : 5 and 10 years usually focal motor ( face and arm) Occur only during sleep or on awakening Symptoms : abnormal movement or sensation around the face and mouth with drooling and a rhythmic guttural sound Benign : Respond promptly to anticonvulsant therapy Brain imaging is normal Epilepsy resolves after puberty

Juvenile myoclonic epilepsy (Janz syndrome):

Juvenile myoclonic epilepsy ( Janz syndrome) Occurs in adolescence Autosomal dominant disorder manifestations : myoclonic jerks in the morning(hallmark) , often causing the patient to drop things; generalized tonic, clonic or tonic- clonic seizures upon awakening; and juvenile absences

Infantile spasms (West syndrome):

Infantile spasms (West syndrome) Ages of onset: 2 - 12 mo (3-8 mo ) Contractions of the neck , trunk , and arm muscles(initial phase consists of flexion and extension in various combinations) lasting 2 to 10 seconds Occur most frequently when the child is awakening from or going to sleep EEG :(waking state) hypsarrhythmia May be mistaken for colic Have a poor prognosis

Etiology of Infantile Spasms (West Syndrome):

Etiology of Infantile Spasms (West Syndrome) Metabolic disorders Phenylketonuria Biotinidase deficiency Maple syrup urine disease Isovalericacidemia Ornithine accumulation Nonketotic hyperglycinemia Pyridoxine dependency Hypoglycemia Lipidosis Developmental malformations Polymicrogyria Lissencephaly Schizencephaly Down syndrome and other chromosomal disorders

Etiology of Infantile Spasms (cont.):

Etiology of Infantile Spasms (cont.) Aicardi syndrome Organoid nevus syndrome Neurocutaneous syndromes Tuberous sclerosis Sturge -Weber syndrome Congenital infections Toxoplasmosis Cytomegalovirus Syphilis Encephalopathies Post-asphyxia Post-traumatic Posthemorrhagic Postinfectious

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Idiopathic or " cryptogenic " group has a better response to therapy than the group with a clear etiology Etiology is determined in 60 % Tuberous sclerosis is the most common recognized cause Treatment options for infantile spasms include ACTH , oral corticosteroids, benzodiazepines, valproic acid, and vigabatrin

Astatic-akinetic or atonic seizures:

Astatic- akinetic or atonic seizures Onset between 1 and 3 years 1 to 4 seconds Characterized by : loss of body tone, with falling to the ground, dropping of the head, or pitching forward or backward Most frequent on awakening and on falling asleep 50 or more daily seizures are usual Developmental delay and underlying brain abnormalities Tuberous sclerosis is a frequent cause

Acquired epileptic aphasia (Landau-Kleffner syndrome):

Acquired epileptic aphasia (Landau- Kleffner syndrome) More common in boys Mean onset of 5.5 yr Confused with autism ( both conditions are associated with a loss of language function) LKF syndrome is characterized by loss of language skills in a previously normal child Hearing is normal , but behavioral problems, including irritability and poor attention span, are particularly common


IMMEDIATE TREATMENT Adequate airway Oxygen is administered Intravenous ( IV) infusion laboratory evaluation Benzodiazepine : Lorazepam (0.05-0.1 mg/kg), diazepam (0.1-0.3 mg/kg), and midazolam (0.2 mg/kg ) Phenytoin (10-15 mg/kg) or fosphenytoin (10-20 mg/kg ) Phenobarbital 10 to 20 mg/kg Valproic acid 20 mg/kg General anesthesia


LONG-TERM THERAPY The overall risk of recurrence for children whose first seizure is generalized tonic- clonic is approximately 50 % healthy child with a single unprovoked partial seizure with a normal neurodiagnostic evaluation, including a normal EEG, may have a recurrence risk of 25 % neurologic abnormality and an abnormal EEG may have a recurrence risk of 75 % Initial drug selection is based on the mechanism of the seizure



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Duration of anticonvulsant treatment varies with seizure type. Children with generalized tonic, clonic , and tonic- clonic seizures; absence seizures ; and certain partial seizures may not require therapy for more than 2 to 4 years Children with juvenile myoclonic epilepsy , progressive myoclonic epilepsy , atypical absence seizures , and Lennox- Gastaut syndrome usually require treatment for life General guidance for families: careful with heights, head injury, and swimming

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